Affidavit of No Insurance
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STATE OF NEW JERSEY )
) SS: AFFIDAVIT OF NO INSURANCE
COUNTY OF )
I, , of full age, being duly sworn according to law, upon my oath, deposes and says:
- On _________________, I was involved in an automobile accident.
- On aforesaid date, I lived at:
- On aforesaid date, I did not own an automobile nor did I reside with anyone who owned an automobile nor did I have a policy of automobile insurance to cover me for this accident.
I certify that the above is true. I am aware that if any of the foregoing is willfully false, I am subject to punishment.
Sworn and Subscribed to before me on
this day of ,200.
ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
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